Risk Stratifying Indeterminate Thyroid Nodules With Machine Learning.

BACKGROUND: Up to 30% of thyroid nodules are classified as indeterminate after fine needle aspiration biopsy. These indeterminate thyroid nodules (ITNs) require surgical pathology for definitive diagnosis. Molecular testing provides additional pre-operative cancer risk stratification but adds expense and invasive testing. The purpose of this study is to utilize a machine learning (ML) algorithm to predict malignancy of ITNs using data available from less invasive tests. MATERIALS AND METHODS: We conducted a retrospective study using medical records from one academic and one community center. Thyroid nodules with an indeterminate diagnosis on fine needle aspiration biopsy and completed diagnostic pathology were included. Linear, non-linear, and non-linear-ensemble ML methods were tested for accuracy when predicting malignancy using 10-fold cross-validation. Classifiers were evaluated using area under the receiver operating characteristics curve (AUROC). RESULTS: A total of 355 nodules met inclusion criteria. Of these, 171 (48.2%) were diagnosed with cancer. A Random Forest classifier performed the best, producing an accuracy of 79.1%, a sensitivity of 75.5%, specificity of 82.4%, positive predicative value of 80.3%, negative predictive value of 79.0%, and an AUROC of 0.859. CONCLUSIONS: ML methods accurately risk stratify ITNs using data gathered from existing, non-invasive, and inexpensive diagnostic tests. Applying an ML model with existing data can become a cost-effective alternative to molecular testing. Future studies will prospectively evaluate the performance of this ML approach when combined with expert judgment.

Evaluating Discrimination of ACS-NSQIP Surgical Risk Calculator in Thyroidectomy Patients.

BACKGROUND: The ACS-NSQIP surgical risk calculator (SRC) often guides preoperative counseling, but the rarity of complications in certain populations causes class imbalance, complicating risk prediction. We aimed to compare the performance of the ACS-NSQIP SRC to other classical machine learning algorithms trained on NSQIP data, and to demonstrate challenges and strategies in predicting such rare events. METHODS: Data from the NSQIP thyroidectomy module ys 2016 - 2018 were used to train logistic regression, Ridge regression and Random Forest classifiers for predicting 2 different composite outcomes of surgical risk (systemic and thyroidectomy-specific). We implemented techniques to address imbalanced class sizes and reported the area under the receiver operating characteristic (AUC) for each classifier including the ACS-NSQIP SRC, along with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at a 5% - 15% predicted risk threshold. RESULTS: Of 18,078 included patients, 405 (2.24%) patients suffered systemic complications and 1670 (9.24%) thyroidectomy-specific complications. Logistic regression performed best for predicting systemic complication risk (AUC 0.723 [0.658 - 0.778]); Random Forest with RUSBoost performed best for predicting thyroidectomy-specific complication risk (0.702; 0.674 - 0.726). The addition of optimizations for class imbalance improved performance for all classifiers. CONCLUSIONS: Complications are rare after thyroidectomy even when considered as composite outcomes, and class imbalance poses a challenge in surgical risk prediction. Using the SRC as a classifier where intervention occurs above a certain validated threshold, rather than citing the numeric estimates of complication risk, should be considered in low-risk patients.

False Negative Rates in Benign Thyroid Nodule Diagnosis: Machine Learning for Detecting Malignancy.

BACKGROUND: Thyroid nodules are common; up to 67% of adults will show nodules on high-quality ultrasound, and 95% of these nodules are benign. FNA cytology is a crucial step in determining the risk of malignancy, and a false negative diagnosis at this stage delays cancer treatment. The purpose of this study is to develop a predictive model using machine learning which can identify false negative FNA results based on less-invasive clinical data. MATERIALS AND METHODS: We conducted a retrospective medical record review at one academic and one community center. Inclusion criteria were thyroid nodules evaluated by ultrasound and FNA with a Bethesda II (benign) result or malignancy detected on pathology or FNA. Linear, non-linear, and ensemble models were generated with scikit-learn using 10-fold cross validation with repetition and compared with AUROC. The classification task was the prediction of malignancy using information acquired from less-invasive ultrasound and FNA. RESULTS: A total of 604 subjects met inclusion criteria; 38 were diagnosed with malignancy. Of all algorithms tested, a Random Forest method achieved the best AUROC (0.64) in separating benign and malignant nodules, though the improvement over other tested algorithms was not statistically significant. CONCLUSIONS: A Random Forest model performed better than random chance using readily available data obtained via standard evaluation of thyroid nodules. The diagnostic probability threshold of this model can be varied to minimize false positives at the cost of increasing the number of false negatives. Future studies will prospectively evaluate the model's performance.

Online Information for Treatment for Low-Risk Thyroid Cancer: Assessment of Timeliness, Content, Quality, and Readability.

The Internet is a key source of health information, yet little is known about resources for low-risk thyroid cancer treatment. We examined the timeliness, content, quality, readability, and reference to the 2015 American Thyroid Association (ATA) guidelines in websites about thyroid cancer treatment. We identified the top 60 websites using Google, Bing, and Yahoo for "thyroid cancer." Timeliness and content analysis identified updates in the ATA guidelines (n = 6) and engaged a group of stakeholders to develop essential items (n = 29) for making treatment decisions. Website quality and readability analysis used 4 validated measures: DISCERN; Journal of the American Medical Association (JAMA) benchmark criteria; Health on the Net Foundation certification (HONcode); and the Suitability Assessment of Materials (SAM) method. Of the 60 websites, 22 were unique and investigated. Content analysis revealed zero websites contained all updates from the ATA guidelines and rarely (18.2%) referenced them. Only 31.8% discussed all 3 treatment options: total thyroidectomy, lobectomy, and active surveillance. Websites discussed 28.2% of the 29 essential items for making treatment decisions. Quality analysis with DISCERN showed "fair" scores overall. Only 29.9% of the JAMA benchmarks were satisfied, and 40.9% were HONcode certified. Readability analysis with the SAM method found adequate readability, yet 90.9% scored unsuitable in literacy demand. The overall timeliness, content, quality, and readability of websites about low-risk thyroid cancer treatment is fair and needs improvement. Most websites lack updates from the 2015 ATA guidelines and information about treatment options that are necessary to make informed decisions.

A Randomized Controlled Clinical Trial: No Clear Benefit to Prophylactic Central Neck Dissection in Patients With Clinically Node Negative Papillary Thyroid Cancer.

OBJECTIVE: The aim of this prospective randomized-controlled trial was to evaluate the risks/benefits of prophylactic central neck dissection (pCND) in patients with clinically node negative (cN0) papillary thyroid cancer (PTC). BACKGROUND: Microscopic lymph node involvement in patients with PTC is common, but the optimal management is unclear. METHODS: Sixty patients with cN0 PTC were randomized to a total thyroidectomy (TT) or a TT+ pCND. All patients received postoperative laryngoscopies and standardized radioiodine treatment. Thyroglobulin (Tg) levels and/or neck ultrasounds were performed at 6 weeks, 6 months, and 1 year. RESULTS: Tumors averaged 2.2 ±â€Š0.2 cm and 11.9% had extra-thyroidal extension. Thirty patients underwent a pCND and 27.6% had positive nodes (all ≤6 mm). Rates of postoperative PTH < 10 (33.3% vs 24.1%, P = 0.57) and transient nerve dysfunction (13.3% vs 10.3%, P = 1.00) were not significantly different between groups. Six weeks after surgery, both TT and TT + pCND were equally likely to achieve a Tg < 0.2 (54.5% vs 66.7%, P = 0.54) and/or a stimulated Tg (sTg) <1 (59.3% vs 64.0%, P = 0.78). At 1 year, rates of Tg < 0.2 (88.9% vs 90.0%, P = 1.00) and sTg < 1 (93.8% vs 92.3%, P = 1.00) remained similar between groups. Neck ultrasounds at 1 year were equally likely to be read as normal (85.7% in TT vs 85.1% in pCND, P = 1.00). CONCLUSIONS: cN0 PTC patients treated either with TT or TT + pCND had similar complication rates after surgery. Although microscopic nodes were discovered in 27.6% of pCND patients, oncologic outcomes were comparable at 1 year.

Thyroid Ultrasound Reports: Will the Thyroid Imaging, Reporting, and Data System Improve Natural Language Processing Capture of Critical Thyroid Nodule Features?

BACKGROUND: Critical thyroid nodule features are contained in unstructured ultrasound (US) reports. The Thyroid Imaging, Reporting, and Data System (TI-RADS) uses five key features to risk stratify nodules and recommend appropriate intervention. This study aims to analyze the quality of US reporting and the potential benefit of Natural Language Processing (NLP) systems in efficiently capturing TI-RADS features from text reports. MATERIALS AND METHOD: This retrospective study used free-text thyroid US reports from an academic center (A) and community hospital (B). Physicians created "gold standard" annotations by manually extracting TI-RADS features and clinical recommendations from reports to determine how often they were included. Similar annotations were created using an automated NLP system and compared with the gold standard. RESULTS: Two hundred eighty-two reports contained 409 nodules at least 1-cm in maximum diameter. The gold standard identified three nodules (0.7%) which contained enough information to calculate a complete TI-RADS score. Shape was described most often (92.7% of nodules), whereas margins were described least often (11%). A median number of two TI-RADS features are reported per nodule. The NLP system was significantly less accurate than the gold standard in capturing echogenicity (27.5%) and margins (58.9%). One hundred eight nodule reports (26.4%) included clinical management recommendations, which were included more often at site A than B (33.9 versus 17%, P < 0.05). CONCLUSIONS: These results suggest a gap between current US reporting styles and those needed to implement TI-RADS and achieve NLP accuracy. Synoptic reporting should prompt more complete thyroid US reporting, improved recommendations for intervention, and better NLP performance.

The Value of the Surgeon Informatician.

Clinical informatics is an interdisciplinary specialty that leverages big data, health information technologies, and the science of biomedical informatics within clinical environments to improve quality and outcomes in the increasingly complex and often siloed health care systems. Core competencies of clinical informatics primarily focus on clinical decision making and care process improvement, health information systems, and leadership and change management. Although the broad relevance of clinical informatics is apparent, this review focuses on its application and pertinence to the discipline of surgery, which is less well defined. In doing so, we hope to highlight the importance of the surgeon informatician. Topics covered include electronic health records, clinical decision support systems, computerized order entry, data analytics, clinical documentation, information architectures, implementation science, quality improvement, simulation, education, and telemedicine. The formal pathway for surgeons to become clinical informaticians is also discussed.

Assessing American Thyroid Association Guidelines for Total Thyroidectomy in Graves' Disease.

BACKGROUND: The American Thyroid Association (ATA) issued specific preoperative preparatory guidelines for patients undergoing thyroidectomy for treatment of Graves' disease. Our goal is to determine if compliance with these guidelines is associated with better outcomes. METHODS: A retrospective review of a prospectively maintained database identified 228 patients with Graves' disease who underwent total thyroidectomy between August 2007 and May 2015. Patients treated in compliance with ATA guidelines were compared with those not in full compliance with the current preparatory guidelines. RESULTS: At the time of surgery, 52% of all patients followed ATA guidelines. Patients who were prepped per ATA guidelines had fewer episodes of intraoperative tachycardia (0.3 versus 4.5, P = 0.04) but had no difference in peak systolic blood pressure or in number of episodes of systolic blood pressure > 180 mmHg. ATA prepped and nonprepped patients had similar mean operating room time and length of stay. ATA prepped and nonprepped patients had similar complication rates, including transient hypocalcemia (30.4% versus 25.5%, P = 0.45), prolonged hypoparathyroidism (0.98% versus 4.3%, P = 0.15), hoarse voice (10.8% versus 7.5%, P = 0.42), permanent recurrent laryngeal nerve paralysis (2.9% versus 2.1%, P = 0.71), and hematoma (2.9% versus 0%, P = 0.09). CONCLUSIONS: Our data suggest that compliance with ATA guidelines for thyroidectomy preparation is not essential for a successful surgical outcome. Although preparation per the guidelines decreased the frequency of intraoperative tachycardia, it did not impact intraoperative hypertension, operating room time, or postoperative complications.

New developments in the diagnosis and treatment of thyroid cancer.

Thyroid cancer exists in several forms. Differentiated thyroid cancers include those with papillary and follicular histologies. These tumors exist along a spectrum of differentiation, and their incidence continues to climb. A number of advances in the diagnosis and treatment of differentiated thyroid cancers now exist. These include molecular diagnostics and more advanced strategies for risk stratification. Medullary cancer arises from the parafollicular cells and not the follicular cells. Therefore, diagnosis and treatment differs from those of differentiated thyroid tumors. Genetic testing and newer adjuvant therapies have changed the diagnosis and treatment of medullary thyroid cancer. This review will focus on the epidemiology, diagnosis, workup, and treatment of both differentiated and medullary thyroid cancers, focusing specifically on newer developments in the field.

Outcomes after completion thyroidectomy versus total thyroidectomy for differentiated thyroid cancer: A single-center experience.

BACKGROUND: Thyroid cancer diagnoses are often discovered after diagnostic thyroid lobectomy. Completion thyroidectomy (CT) may be indicated for intermediate or high-risk tumors to facilitate surveillance and/or adjuvant treatment. The completeness of thyroid resection and the safety of CT compared to total thyroidectomy (TT) is unclear. We assessed outcomes after TT or CT to determine completeness of resection and risk of complications. METHODS: Patients undergoing TT or CT between 2000 and 2018 were retrospectively reviewed. Pathology, unstimulated thyroglobulin (uTg), parathyroid hormone (PTH), rates of hematoma, and recurrent laryngeal nerve (RLN) injury were compared. RESULTS: Differentiated thyroid cancer (DTC) was identified in 954 patients undergoing TT and 142 patients undergoing CT. Postoperative uTg at 6 months was not different between TT and CT, 0.2 vs 0.2 ng/mL, P = .37. Transient hypoparathyroidism with immediate postoperative PTH less than 10 was more common after TT, 14.3 vs 6.0% (P = .009). No differences were noted regarding postoperative hematoma, transient RLN injury, permanent hypoparathyroidism, and permanent RLN injury. CONCLUSIONS: If CT is required for DTC, a complete resection, as assessed by postoperative uTg, can be achieved. Furthermore, CT is significantly less likely to result in transient hypoparathyroidism and poses no additional risk of RLN injury, hematoma, or permanent hypoparathyroidism.

Failure to Diagnose and Treat Hyperparathyroidism Among Patients with Hypercalcemia: Opportunities for Intervention at the Patient and Physician Level to Increase Surgical Referral.

BACKGROUND: Hyperparathyroidism is both underdiagnosed and undertreated, but the reasons for these deficiencies have not been described. The purpose of this study was to identify reasons for underdiagnosis and undertreatment of hyperparathyroidism that could be addressed by targeted interventions. MATERIALS AND METHODS: We identified 3,200 patients with hypercalcemia (serum calcium >10.5 mg/dL) who had parathyroid hormone (PTH) levels evaluated at our institution from 2011 to 2016. We randomly sampled 60 patients and divided them into three groups based on their PTH levels. Two independent reviewers examined clinical notes and diagnostic data to identify reasons for delayed diagnosis or referral for treatment. RESULTS: The mean age of the patients was 61 ± 16.5 years, 68% were women, and 55% were white. Fifty percent of patients had ≥1 elevated calcium that was missed by their primary care provider. Hypercalcemia was frequently attributed to causes other than hyperparathyroidism, including diuretics (12%), calcium supplements (12%), dehydration (5%), and renal dysfunction (3%). Even when calcium and PTH were both elevated, the diagnosis was missed or delayed in 40% of patients. For 7% of patients, a nonsurgeon stated that surgery offered no benefit; 22% of patients were offered medical treatment or observation, and 8% opted not to see a surgeon. Only 20% of patients were referred for surgical evaluation, and they waited a median of 16 months before seeing a surgeon. CONCLUSION: To address common causes for delayed diagnosis and treatment of hyperparathyroidism, we must improve systems for recognizing hypercalcemia and better educate patients and providers about the consequences of untreated disease. IMPLICATIONS FOR PRACTICE: This study identified reasons why patients experience delays in workup, diagnosis, and treatment of primary hyperparathyroidism. These data provide valuable information for developing interventions that increase rates of diagnosis and referral.

Utility of Early Postoperative Unstimulated Thyroglobulin in Influencing Decision Making in Patients with Papillary Thyroid Carcinoma.

BACKGROUND: Serum thyroglobulin is used to screen for disease persistence or recurrence of papillary thyroid carcinoma (PTC). We sought to assess the utility of early postoperative unstimulated thyroglobulin levels (uTg) as a decision-making tool to guide the use of radioactive iodine (RAI) in PTC patients. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients surgically treated for PTC from 2015 to 2017. We analyzed uTg approximately 6 weeks postoperatively. Patients undergoing total thyroidectomy or completion thyroidectomy were included in the study, and patients were analyzed according to postoperative uTg and receipt of RAI. RESULTS: A total of 255 patients were analyzed, with 134 patients meeting the inclusion criteria. The median postoperative uTg was 0.3 ng/mL. Overall, 49.3% (66/134) of patients achieved the target uTg of ≤ 0.2 ng/mL at a mean time of 7.9 ± 0.3 weeks postoperatively; 60% (40/66) of patients who achieved uTg ≤ 0.2 ng/mL postoperatively did not receive RAI. A uTg ≤ 0.2 ng/mL was maintained at 6 months in 98.1% of patients, including 100% of patients who received RAI and 96.7% of patients who did not receive RAI (p = 0.8). Of those who did not receive RAI, none demonstrated structural disease recurrence on 6-month ultrasound. Patients with early postoperative uTg > 0.2-2.0 ng/mL showed benefit from RAI, while patients with uTg > 2.0 ng/mL did not achieve the targeted uTg level regardless of receipt of RAI. CONCLUSIONS: Postoperative uTg may be used to guide the use of RAI. Achieving near-undetectable uTg within 6 weeks postoperatively could aid providers in assessing disease burden and minimize RAI use for patients with a low-risk of disease recurrence. Continued follow-up is necessary to accurately determine long-term outcomes.

Identifying Predictors of Prolonged Levothyroxine Dose Adjustment After Thyroidectomy.

BACKGROUND: Levothyroxine (LT4) is one of the most prescribed drugs in the United States; however, many patients started on LT4 after thyroidectomy suffer from symptoms of hyper- or hypo-thyroidism before achieving euthyroidism. This study aims to describe the time required for dose adjustment before achieving euthyroidism and identify predictors of prolonged dose adjustment (PDA+) after thyroidectomy. METHODS: This is a single institution retrospective cohort study of patients who achieved euthyroidism with LT4 therapy between 2008 and 2017 after total or completion thyroidectomy for benign disease. Patients who needed at least three dose adjustments (top quartile) were considered PDA+. Binomial logistic regression was used to identify predictors of PDA+. RESULTS: The 605 patients in this study achieved euthyroidism in a median of 116 d (standard deviation 124.9) and one dose adjustment (standard deviation 1.3). The 508 PDA- patients achieved euthyroidism in a median of 101 d and one dose adjustment. The 97 PDA+ patients achieved euthyroidism in a median of 271 d and three dose adjustments. Iron supplementation (odds ratio = 4.4, 95% confidence interval = 1.4-13.5, P = 0.010) and multivitamin with mineral supplementation (odds ratio = 2.4, 95% confidence interval = 1.3-4.3, P = 0.004) were independently associated with PDA+. Age, gender, preoperative thyroid disease, and comorbidities did not independently predict PDA+. CONCLUSIONS: After thyroidectomy, achieving euthyroidism can take nearly 4 mo. Iron and mineral supplementation are associated with PDA+. This information can inform the preoperative counseling of patients and suggests that this may expedite achieving euthyroidism.

Optimizing Levothyroxine Dose Adjustment After Thyroidectomy With a Decision Tree.

BACKGROUND: After thyroidectomy, patients require Levothyroxine (LT4). It may take years of dose adjustments to achieve euthyroidism. During this time, patients encounter undesirable symptoms associated with hypo- or hyper-thyroidism. Currently, providers adjust LT4 dose by clinical estimation, and no algorithm exists. The objective of this study was to build a decision tree that could estimate LT4 dose adjustments and reduce the time to euthyroidism. METHODS: We performed a retrospective cohort analysis on 320 patients who underwent total or completion thyroidectomy at our institution. All patients required one or more LT4 dose adjustments from their initial postoperative dose before attaining euthyroidism. Using the Classification and Regression Tree algorithm, we built various decision trees from patient characteristics, estimating the dose adjustment to reach euthyroidism. RESULTS: The most accurate decision tree used thyroid-stimulating hormone values at first dose adjustment (mean absolute error = 13.0 µg). In comparison, the expert provider and naïve system had a mean absolute error of 11.7 µg and 17.2 µg, respectively. In the evaluation dataset, the decision tree correctly predicted the dose adjustment within the smallest LT4 dose increment (12.5 µg) 79 of 106 times (75%, confidence interval = 65%-82%). In comparison, expert provider estimation correctly predicted the dose adjustment 76 of 106 times (72%, confidence interval = 62%-80%). CONCLUSIONS: A decision tree predicts the correct LT4 dose adjustment with an accuracy exceeding that of a completely naïve system and comparable to that of an expert provider. It can assist providers inexperienced with LT4 dose adjustment.

Timely Evaluation and Management of Primary Hyperparathyroidism in Patients With Kidney Stones.

BACKGROUND: Nephrolithiasis is a classic, treatable manifestation of primary hyperparathyroidism (PHPT). We examined predictors of kidney stone formation in PHPT patients and determined how efficiently the diagnosis of PHPT is made in patients whose initial presentation is with stones. MATERIALS AND METHODS: We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone formers and 1047 patients with no kidney stones. We also analyzed 51 stone-forming patients whose stone evaluation and treatment were completed within our health system before PHPT diagnosis. RESULTS: Stone-forming patients had higher 24-h urinary calcium (342 versus 304 mg/d, P = 0.005), higher alkaline phosphatase (92 versus 85 IU/L, P = 0.012), and were more likely to be normocalcemic (26.6% versus 16.9%, P = 0.001). Surprisingly, 47.3% of stone formers had normal urinary calcium levels (<300 mg/d). Of the 51 stone-forming patients treated at our institution, serum calcium was measured within 6 mo of stone diagnosis in 37 (72.5%) patients. Only 16 (31.4%) of these patients had elevated calcium levels, and only 10 (62.5%) of these 16 had a serum parathyroid hormone ordered within the following 3 mo. These patients had a significantly shorter time from their first stone to surgical treatment compared to other patients (median 8.5 versus 49.1 mo, P = 0.001). CONCLUSIONS: Elevated serum and urinary calcium levels are not evaluated in the majority of PHPT patients presenting with kidney stones. In nephrolithiasis patients, provider consideration of PHPT with prompt serum calcium and parathyroid hormone evaluation significantly reduces time to treatment.

Survival in patients with medullary thyroid cancer after less than the recommended initial operation.

BACKGROUND AND OBJECTIVES: We aimed to evaluate the disease specific-survival (DSS) of patients with Medullary Thyroid Cancer (MTC) confined to the central neck based on the extent of the initial operation. METHODS: This retrospective review of patients with MTC from the SEER registry from 2004 to 2012 excluded patients with lateral neck involvement or distant metastases. RESULTS: The cohort (n = 766) included 85(11%) less than total thyroidectomies (TT), 212(28%) TT alone, and 469(61%) TT with lymph node excision. Mean tumor size was similar (2.2cm for

Intraoperative Parathyroid Hormone Levels at 5 min Can Identify Multigland Disease.

BACKGROUND: Intraoperative parathyroid hormone (IOPTH) monitoring is crucial in the treatment of primary hyperparathyroidism (PHPT). Often, the 5 min IOPTH levels fall, but not by the requisite 50 %. In such cases, the surgeon must decide whether to wait for additional levels or to continue exploration. This study aimed to evaluate the 5 min drop in IOPTH for distinguishing single adenomas (SA) from multigland disease. METHODS: A retrospective analysis of a prospectively collected database was performed on PHPT patients who underwent initial curative parathyroidectomy between 2001 and 2013. Those with familial disease and those taking lithium or undergoing concomitant thyroidectomy were excluded from the analysis. For cases of double adenomas (DA) or hyperplasia (HA), the IOPTH values indicating additional glands were analyzed. RESULTS: The inclusion criteria were met by 1021 patients: 817 patients with SA (82.2 %), 99 patients with DA (10 %), and 78 with HA (7.9 %). The SA patients exhibited a 56.6 ± 4.9 % decline in IOPTH at 5 min compared with 21.3 ± 4.5 % of the DA patients and 22.5 ± 4.3 % of the HA patients (p < 0.01). Post hoc comparisons showed that the 5 min decrease in the SA group was significantly greater than in either the DA group or the HA group (p < 0.01). A 5 min percentage decline of 35 % best distinguished SA from multiglandular disease (85.3 vs. 24.9 %). CONCLUSION: The data suggest that when IOPTH level does not drop by at least 35 % at 5 min after excision, the surgeon should consider further exploration rather than wait for additional levels.

Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma.

BACKGROUND: The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. METHODS: We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. RESULTS: We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar. CONCLUSION: Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.

Optimizing Outpatient Pain Management After Thyroid and Parathyroid Surgery: A Two-Institution Experience.

BACKGROUND: Thyroidectomy and parathyroidectomy are the most commonly performed endocrine operations, and are increasingly being completed on a same-day basis; however, few data exist regarding the outpatient postoperative pain requirement of these patients. We aimed to describe the outpatient narcotic medication needs for patients undergoing thyroid and parathyroid surgery, and to identify predictors of higher requirement. METHOD: We examined patients undergoing thyroid and parathyroid surgery at two large academic institutions from 1 January-30 May 2014. Prospective data were collected on pain scores and the oral morphine equivalents (OMEQs) taken by these patients by their postoperative visit. RESULTS: Overall, 313 adult patients underwent thyroidectomy or parathyroidectomy during the study period; 83% of patients took ten or fewer OMEQs, and 93% took 20 or fewer OMEQs. Patients who took more than ten OMEQs were younger (p < 0.001) and reported significantly higher overall mean pain scores at their postoperative visit (p < 0.001) than patients who took fewer than ten OMEQs. A multivariate model was constructed on pre- and intraoperative factors that may predict use of more than ten OMEQs postoperatively. Age <45 years (p = 0.002), previous narcotic use (p = 0.037), and whether parathyroid or thyroid surgery was performed (p = 0.003) independently predicted the use of more than ten OMEQs after surgery. A subgroup analysis was then performed on thyroidectomy-only patients. CONCLUSION: Overall, 93% of patients undergoing thyroidectomy and parathyroidectomy require 20 or fewer OMEQs by their postoperative visit. We therefore recommend these patients be discharged with 20 OMEQs, both to minimize waste and increase patient safety.

Variation in the Types of Providers Participating in Breast Cancer Follow-Up Care: A SEER-Medicare Analysis.

BACKGROUND: The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers. METHODS: Stages 1-3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care. RESULTS: Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year). CONCLUSIONS: Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers' responsibilities during follow-up care could lead to improved efficiency and quality of care.